Birth by fire: a look at how military emergency care influenced civilian care

Note: This entry was originally posted on a blog I created for my History of Medicine class final project during December 2012.

US Army Manual

When the National Academy of Sciences published its White Paper in 1966, it found civilian EMS services woefully inadequate, yet praised the military, stating: "Excellence of initial first aid, efficiency of transportation, and energetic treatment of military casualties have proved to be major factors in the progressive decrease in death rates of battle casualties reaching medical facilities, from 8 percent in World War I, to 4.5 percent in World War II, to 2.5 percent in Korea, and to less than 2 percent in Vietnam."

Unsurprisingly, the NAS recommended emulating military techniques. I was curious what the military was doing that worked so well, beyond simply removing injured soldiers from the battlefield with great speed (I've already covered some of its transportation techniques in my Hemingway post). To answer my question, I happened to find a 1950 edition of US Army Manual TM8-230, Medical and Surgical Technicians (search the text here). That this manual was written in 1950 means its authors had the benefit of discovering what worked well and what didn't work well for emergency medicine in the World Wars. Its age also means that these were military standards that would have been implemented over a decade before the NAS began evaluating EMS in the states. (A 1930 edition is available; a brief preview offered by Google suggests it had similar, if not as advanced or thorough, contents, but I haven't been able to find a copy of the whole book for a proper comparison. No doubt many other year editions exist. I'd love to see what the current issue looks like.)

Table of Contents

The first thing I noticed about the manual was just how thick it was. I'd entered with preconceived notions about what to expect from emergency medical care of the era, and I'd supposed I'd find a relatively thin document. However, Manual TM8-230 clocks in at around 600 pages and is divided into four sections: 1) Anatomy and Physiology, 2) Emergency Medical Treatment, 3) Pharmacology and Materia Medica, and 4) Dispensary Procedures. The manual was geared toward two different, but related, military occupations: the medical technician and the surgical technician. The medical technician worked in the battlefield and would have been most interested on the material in section two, which was generally aimed at the field treatment of acute injuries and illnesses. The latter surgical technician functioned mainly in the hospital and would have studied section four, which dealt more or less with nursing procedures. (These distinct professions are alive and well in the US Army today, although they've been renamed: medical technicians are now called "health care specialists" and surgical technicians are now called "operating room specialists".) However, the overlap between the material, and the practicality for one specialist to at least have some training in the other's field, made it a smart move to combine both curricula into one manual.

Emergency care defined

As I read through the manual, I again was very surprised at how similar the training the medical technicians underwent in 1950 was to the training I underwent as an EMT student in 2012. I didn't feel as if I was looking into a manual that was over sixty years old, but rather, that I was looking at a slightly different version of the textbook used in my class. These technicians were expected to not only apply treatments, but to understand the anatomy and physiology that guided them; they were also expected to learn how the healing process worked. The technician thought not only about the short-term effects of his techniques, but also the long-term. The Army clearly distinguished between the basic first aid any bystander could provide, and a new kind of professional who could do and understand more:

Emergency medical treatment is the care given to an ill or injured person until he can be given definitive (complete) treatment. The purpose of emergency medical treatment is to save life, to prevent further injury, and to preserve resistance and vitality. In the Army, medical treatment is that which is given by Medical Department personnel. The term first aid is used to describe the care given casualties before regular medical or surgical treatment can be administered. (p. 87)

Anatomy sample

In some ways, in fact, the manual's breadth was more in-depth that the current curriculum for EMT-Basics -- these medical technicians were taught to perform advanced lifesaving techniques that modern civilian EMT-Basics, such as myself, are simply forbidden from performing. (This problem continues today; military medics still learn and do much more than the majority of civilian medics, and in October 2012, John Stewart aired a segment on the problems veterans face re-integrating into civilian EMS systems, where they are no longer permitted to perform the advanced skills they used to save soldiers' lives.) Of course, although some of the information was outdated by modern standards, much of its hold today, and many of the techniques it teaches are still employed: the emphasis on the airway -- if you can't breathe, you can't live!, the ubiquitous use of oxygen, the administration epinephrine for certain conditions, I could go on and on. I don't know whether this timeliness speaks to just how advanced military emergency medicine was, or if it confirms complaints by some researchers (the NAS would tackle EMS again in 2007, as discussed in my essay) that EMS stubbornly clings to traditional practices to the detriment of the field. However, considering that those same researchers also praised civilian EMS for its vast improvements and the numbers of lives saved, I'd tend to think that the former is more true than the latter, which makes this historical manual quite amazing. No wonder the 1966 NAS was impressed!

Physiology sample

Types of wounds

More types of wounds

Treating shock - not much has changed!

Elevating feet to fight shock is still done today

Applying a tourniquet

Artificial respiration by rocking seems silly to today's EMTs who use bag valve masks to breathe for patients; however, using gravity to force air into a man's lungs was pretty brilliant!

Treating an open chest wound

Today we use OPAs to keep a man's tongue from falling into his airway, but this must have done the job quite well, too!

Medical technicians could administer morphine in the field; only highly trained civilian paramedics can do this today

The "log roll" is still used to move patients with a compromised spine

Splinting a leg

Medical technicians applied hemostats to bleeding vessels

Dealing with fractures

A typical first aid kit that would be carried by all soldiers

Medical technicians then probably hated studying drug calculations just as much as modern EMTs do

Splinting a broken neck - the original cervical collar (c-collar)?

Treatment for bleeding - not much has changed!

I wonder how often technicians dealt with "acute alcoholism" (based on how frequently VDs were mentioned, they must have been quite the problem!)?

Prone artificial respiration is no longer used (it looks kind of like backwards CPR) but the emphasis on the airway remains!

The sizable manual held by a young 20-something-year-old man (thanks to my boyfriend for posing), as it probably was many years ago